An Apple A Day

If you read about vitamin supplements you must be confused.  Actually, it would be hard not to be. Vitamins are, by definition, essential to health.  Studies of hundreds of millions of people confirm that truth. However, a rash of recent studies have linked taking vitamin supplements to higher rates of a variety of diseases, especially cancer.  What’s up?

 

The fundamental problem is bad research.  This bad research is the consequence of poor understanding, plus the difficulties inherent in designing and conduct nutritional studies that apply to the real world.  The best examples of the faults in these nutritional studies are probably those dealing with folic acid and vitamin E.  

 

Many studies show that dietary folic acid reduces the risk of many diseases, particularly cancer.  The prevention of congenital spinal malformations is the main reason our food supply has been fortified with folic acid for decades.  Surveys of the American population show that this approach works.  That is the simple part.  The confusing part is that some studies have shown an increased risk of cancer with folic acid supplementation, while others have shown that folic acid lowers the risk of the very same cancers.

 

As many of you have heard me explain following your own blood testing, nearly 20% of us have a genetic inability to convert folic acid to its metabolically active form.  Those individuals among us need to take a special form of folate.  If they take the common, most widely available kind of folic acid, not only does it not help, it seems to cause problems consistent with the unhappy research findings. After MERCK, which holds a patent on this form of folic acid, allowed others to use it, I had it added to my multiple vitamin.  Very few multiple vitamins contain this form of folic acid, as it is more expensive.  Two months ago I read an editorial in a major medical journal wherein a couple of prominent experts pointed out that negative studies on folic acid in diabetics had neglected to address this issue.  Their opinion, with which I am in complete agreement, was that these studies were fundamentally flawed and almost certainly drawing incorrect conclusions as a consequence.

 

Vitamin E has also taken a lot of heat due, to a similar lack of understanding.  Most of the vitamin E you can buy in supplements comes as alpha tocopherol.  Unless you are a chemist, your brain won’t want to swallow that word or distinguish it from beta, gamma, delta or any other tocopherols.  It is not even that simple, because even with all of those tocopherols, an additional class of compounds called tocotrienols are part of the Vitamin E family and seem to be important.  Food contains all of these compounds, and it appears that alpha tocopherol might be the least important of all.  As one vitamin E researcher wrote, “taking a mixture of vitamin E that resembles what is in our diet would be the most prudent supplement to take”.  I would amend that statement to read, “taking a mixture of vitamin E that resembles what would be in an ideal diet and considers your individual needs, would be the most prudent supplement to take”.

 

A recent survey concluded that very few Americans were low on any vitamins or minerals.  While that got significant media attention, the fact that hundreds of studies have shown the opposite, did not.  Many of those studies actually measured body levels.  That is especially important as estimates from dietary records are woefully misleading.  Dietary records are infamously different from the truth of what people really do eat.  On top of that, absorption varies tremendously from person to person and even time to time for the same person.

 

Thankfully, there is evidence that some who write about and study nutrition are thinking more clearly.  The “experts” are becoming more expert.  Also, those with a better understanding are getting at least some attention for their criticisms.

 

Positive evidence of the benefits of dietary supplementation continues to accumulate (of course).  Recent studies have shown that the brains of people of all ages, from young children to elderly adults, function better beginning just days after starting to take a multiple vitamin.  The same holds true of omega-3 supplements. In an example of the complexity of nutrient interaction, vitamin E lowers the rate of prostate cancer but only when taken along with selenium.

 

Bottom line-

Think critically -  If something is vital, many of us need it.

Don’t forget the food – A vitamin pill cannot entirely replace good food.  

Don’t go crazy -  Take moderate amounts of nutrients as a safety net.

Go crazy if YOU need to -  Some people, especially when ill, need much more.

Vitamins vary – Cheap forms of nutrients cost less, but they are usually a waste of money and can be harmful

 

 

 

I hope that, respecting tradition, you have dedicated yourselves to creating some better health habits in this New Year.  I also hope that you are going about that in a joyful way, understanding that doing the right things will help you enjoy your life more.  Also, pursuing good health habits should be fun, not tedious and just “good for you”.  Sure, sometimes it takes a little while before you start noticing the benefits, so a little discipline is needed to establish your new habits.  Other times, you feel better right away.  Instantaneously or gradually, disease-reducing, longevity-promoting or not, do it because you will feel better. This newsletter is a map, guiding you along the most direct path towards a better life. Change is not just a matter of will-power. Going about it the right way makes it much easier, and markedly increases your chances of success.

I am in an exercise focus right now.  Admittedly, some of that is because of the time I spent during the last month working at the Olympic Marathon Trials and attending a sports nutrition conference, but more importantly, a lot of new data is coming out that is very interesting and will be useful to you. In this blog I will soon post some thoughts about some physical training specifics.  The purpose will be to make your exercise more efficient and more effective.

Making changes

The idea of making changes in the New Year is easy fodder for comedians.  Everyone talks about it, but no one really accomplishes anything.  That’s right and it’s also very wrong.

In the Northern Hemisphere, where most of us live, the New Year roughly marks the return of the sun.  The days start to become longer and warming weather will follow.  Greeting the New Year with hope and new ideas has been the tradition as far back as we can trace human cultural history.  I think this tradition would have died out long ago if every attempt were met by failure.  On the contrary, every day I see patients successfully change their lives for the better, not just at the New Year.  You should be optimistic about making changes.

Change doesn’t happen simply by rolling out of bed on New Year’s Day, although that IS a necessary first step.  To ensure success, you need to develop a plan.

Self-Assessment

The dark, cold months of the year are traditionally a time of reflection, a time of the inner life.  Figuring out where you are is essential to creating a map to get you where you want to be.

I cannot overemphasize how important an honest and thorough self-assessment is when you are trying to make changes.  Your self-assessment must be as objective as you can make it.  An inaccurate assessment inevitably carries the seeds of failure.  If you think you are in better shape than you really are, the training for that April marathon WILL injure you.  You might think you aren’t eating well enough when your lack of exercise or poor stress-management is the bigger issue.

We usually perceive some problems clearly, but others we think are bigger than they really are, while still others are invisible to our own eyes. Trying to sort things out by yourself can be a lot like painting a self portrait without a mirror, or maybe having only a distorted, funhouse mirror to look at.  This is the reason so many people find the help of a professional useful.  A professional can identify problems and solutions you might not recognize or know about.  A professional should have learned from the experience of many patients and can use that accumulated wisdom to guide you.  Seeking the advice of family and friends can also be helpful at times.

Reflection is an inward, ideally a meditative, process.  In keeping with that inwardness we should start from the inside, meditating on who we are and who we want to become.  Following is a list of some areas to consider:

Essential health habits

Drink Enough Water

Exercise Almost Every Day

Eat Well

Take Your Supplements

Avoid The Things That Make You Sick

Get Enough Sleep

Be Involved in Your Community

Have A Healthy Sex Life

Remember That Attitude Is Important

Spirituality/Life purpose

Goal Setting

After you sort out where you are, you can create an image of where you want to be and construct a map to get you there. Deciding that you want to be younger is not going to work anymore than deciding you want to be taller or win the lottery.  Make your goals achievable!  That is the first step in goal setting.

In a more subtle way, deciding that you want to be stronger or thinner or calmer won’t work either.  There is an art to creating goals that will help you achieve success.

Second Step – Goals Must Be Specific

If you set a goal but don’t have a path to follow towards the goal, or you don’t know when you are there, you won’t ever get there.  For example, you decide that you want to lose weight. You then must sort out how you are going to do that and how you are going to measure it.  Let’s say you determined that, for you, the keys to improved health are to increase your activity and change your diet by eating more vegetables and cutting out soda and alcohol.

You could begin by tracking your activity level for a week, either by timing yourself, or better still, wearing a pedometer.  Then, as you set about implementing the changes, you have clear evidence and incentive by simply reading the numbers.

The same applies to your diet.  You could decide that you will eat some vegetables at every meal, including two servings at lunch and dinner with a leafy green salad every night.  You also determine to limit yourself to no more than one alcoholic drink and one soda a week.  All you have to do is look at your plate and into your drinking glass to learn whether you are reaching your goals.

I have a couple of comments about weight loss as a goal.  First, it is not a particularly health oriented goal, so I don’t like it much.  As long as you are sort of close to “normal”, other factors (especially physical fitness) are much more important than the reading on the scale.  There is some evidence that, as long as you are physically fit (i.e., good aerobic capacity and strength), obesity might not be a risk factor for death, disease or feeling poorly.  The scale does not tell you what you are made of, your body composition.  Most people who do a lot of strength training are overweight on the charts, but have low body fat.  Increased levels of body fat are more risky than similar increases in body weight. Many people find that improving their diet and exercise pattern does not change their weight as much as it changes how they feel, their physical capacity and how their clothes fit.  Muscle is denser than fat, so patients usually tell me their clothes are fitting looser even when their weight has not changed significantly.

Third Step – Early Success

To maintain and build on a change we need positive feedback.  If you try to do too much, feel horrible while doing it and feel worse the next day, how likely are you to try it again?

Creating those specific, achievable goals helps you set in motion a positive feedback cycle.  You met your goal.  What you did made you feel better.  You felt good because you met your goal.  You then want to keep it going.  It is vital to let yourself feel good about your accomplishment.  CELEBRATE YOUR SUCCESSES!

Short-term vs Long-term Goals

Tied closely to the concept of early success is the distinction between short and long-term goals.  If you are only going to be satisfied when you have gone all the way from couch potato to triathlete, you are going to be unhappy for a long time and probably never going to become a triathlete.

Short-term goals are the steps on your path.  Long-term goals are the destinations to where the path leads you.  If you think only about the beach, you are going to get lost on the path through the jungle.

Taking Action

Implementing your strategy requires determination, but it also demands gentleness.  Living with a drill sergeant is not going to work, especially if YOU are the drill sergeant. For some patients I need to be a cheerleader, doing everything I can to convince them of the need for change and applauding their positive steps.  For many others, particularly those who are less healthy than they used to be because of age, illness or they just let themselves go, I have to work hard to reign in their over-enthusiasm.

Particularly with exercise, it is very easy to do too much too fast.  The consequence is often an injury, and the time then needed for recovery often sets the patient further back than she/he was to begin with.  You will make the fastest progress by going slow.  When increasing physical activity, I tell all but the youngest, strongest patients to increase EITHER intensity or duration by 10% a week.

The other side of it is that changing several problem areas in your life at the same time can be very good and a highly successful approach.  Diet changes in particular are often most successful when they are dramatic.  You feel better quickly and that experience helps you do more.  As you feel the benefit, your commitment will be stronger and you will have more energy to do more to feel better still.

The greatest wisdom is in simply paying attention to how you feel and adjusting accordingly.

Failure

The road of excess leads to the palace of wisdom – William Blake

Failure is good.  It is good because we have to make mistakes to learn.  When I see a patient who has not implemented my recommendations I always want to know why.  Actually I have to understand why they failed, in order to help them go further.  Problem-solving is an inevitable part of doing anything new.  If I recommend swimming for a patient with back trouble as the best exercise for her condition, but she can’t swim, what is the point?  If a patient has not been using the breathing exercise I recommended because he did not understand it, I need to make it clearer.

The only real mistakes are those that we do not learn from.  Mistakes teach us how to correct our course before we get way off track.  If you haven’t made mistakes, you haven’t been trying.

900 pages and zero thought. That is my summation of the IOM’s new calcium and vitamin D statement. Having been a member of such consensus panels in the past, I am sympathetic to their tendency to fall to the most conservative “lowest common denominator” opinion. However, this document is far from a reasonable scientific assessment. Considering the research they ignored and my clinical experience, I am disappointed for the people who will suffer needlessly.

Go to http://www.grassrootshealth.net/iomquotes if you want to read comments from other scientists. Also, the Vitamin D Council is filing a request under the Freedom of Information Act that IOM release the recommendations submitted to them by vitamin D researchers and Walter Willett from Harvard, all of whom supposedly recommended higher standards than IOM.

The most frequent supplement question I’ve been hearing lately is about taking calcium. These questions have been inspired by a recent study of calcium supplementation, which received a great deal of attention. The authors of this study combined data from other studies and determined that calcium supplementation increased the risk of heart attack.

Most of us get way less calcium in our diets than is recommended. Calcium is vital to a broad range of biological processes (heart rhythm, immunity, cancer protection, etc) and not just bone formation, as some assume. Calcium is unlike most other dietary nutrients in that it is so vitally important that the body maintains a huge stockpile of the nutrient (our bones) and then routinely breaks into that store to maintain a precise level in the blood. The body works very hard to keep calcium blood levels in that very narrow range, and even slight deviations occur only with serious problems.

Long ago our ancestors consumed much more calcium than we do. Today calcium supplementation is both common and apparently necessary, as so few of us consume recommended levels in our diet.

There have been hundreds of clinical trials involving calcium and heart disease. They only used the data from 15 of those studies. Demonstrating their own lack of understanding and naivete, they repeated the erroneous conclusion that calcium does not build bones (You can dig back in my old newsletters to read my discussion of that very poor study which they cited, but in fact proved just the opposite). If the increased risk of heart attack was meaningful, one would expect the risk of death from heart attack to also increase. It did not. Because they are they same process, only in different parts of the body, the risk of stroke should also have increased, but it did not.

In a lamentable declaration of enthusiasm for medication and radiation, one of the study authors recommended that patients get bone scans and wrote “If their risk is high, they should consider using medications rather than calcium supplements”. Reflecting a similar promedication bias, an accompanying editorial written by English cardiologists recommended “Given the uncertain benefits of calcium supplements, any level of risk is unwarranted…. On the basis of the limited evidence available, patients with osteoporosis should generally not be treated with calcium supplements, either alone or combined with vitamin D, unless they are also receiving an effective treatment for osteoporosis.” They also recommended diuretic drugs, which theoretically might increase bone density, while claiming that supplements are ineffective, dangerous and a waste of time.

Ignoring calcium and D, this is like dumping synthetic fertilizer on your garden without giving the plants water and sunshine. Not terribly smart.

Magnesium and calcium both compete and complement each other metabolically. Too much of either relative to the other can create risks. Similarly, as calcium barely dissolves in water and most people drink too little water, ignoring fluid intake can lead to false conclusions. As you have probably anticipated, I will also criticize their overlooking the influence of vitamin D, which is essential to most aspects of calcium metabolism and perhaps the most glaring vitamin deficiency in the world.

One of the world’s foremost experts on calcium metabolism, Dr Robert Heaney, commented that the paper was highly suspect. His group had conducted many of the studies reanalyzed by the investigators in the current meta-analysis. Heaney also said that, using the same data, the New Zealand investigators reached the opposite conclusions than his group and chose not to include data from other studies conducted by Heaney’s group.

I am especially interested in Dr Heaney’s comments, for several reasons. He is a member of the panel that sets recommended calcium intake levels in the US. Several years ago he wrote an extremely interesting article on the very high calcium intake of our ancient ancestors and the broad health impacts of calcium. He was also one of the handful of speakers at the first national medical meeting focused on the growing body of information on vitamin D. I spoke to him at that meeting, specifically questioning whether recommended calcium levels were too high, as they ignored widespread vitamin D deficiency. He convinced me that that was unlikely.

I am also a bit uncomfortable about this new study for a couple of unusual reasons. First, the lead author has been an investigator in many of the negative studies of calcium supplementation. That is more notable, given that the majority of clinical studies have not reached negative conclusions. Secondly, the team of investigators reside in New Zealand and are funded by the New Zealand government. As milk is an important income source for the country, they often fund investigations which tout the health effects of milk. This includes milk as a calcium source compared to supplementation. However, neither of these is proof of bias.

My conclusions are:
1) As I have instructed so many of you in the office – diet is best (see list at-
http://www.carlstonmd.com/docs/calcium.htm)
2) The recommended calcium intakes are reasonable. If you eat a lot of meat, you might need a bit more, or a bit less if you don’t.
3) Looking at dietary logs of many thousands of patients over the last 30 years, I can confidently state that most of us need to supplement our dietary calcium intake.
4) The kind of calcium supplement is important (calcium citrate and calcium malate are the safest and best absorbed)
5) Other factors like water, magnesium and vitamin D are essential to proper absorption and utilization of calcium.

It seems that warmer weather might actually be peaking shyly and belatedly around the corner. The odd weather has not been unique to Sonoma County. I attended an excellent meeting on the treatment of cancer with nutrition and alternative therapies near San Diego, and it was even cooler than here. Honestly, even it were snowing or dumping cold rain, the meeting was so good that I would not have much noticed the weather. It has taken far too long, but the medical climate is also changing growing awareness, supported by scientific study, of the vital impact of nutrition, a broad range of environmental factors and supplements on both the prevention and treatment of cancer. Since the meeting, and reflecting increasingly rational attitudes in medicine, a study was published showing that intravenous vitamin C cut cancerous tumor size and growth in mice by approximately one half. I expect to write more about information presented at the cancer meeting in the near future.

Now that my MVM is available for sale on Amazon, it might be more convenient for many of you to order it that way, and certainly easier for your friends and family living at a distance. As we need to establish ourselves on Amazon, every time you or someone you refer orders my MVM on Amazon up until October 1, Melanie will credit your account $5 towards a nonMVM supplement purchase through the office. Contact Melanie for any questions by calling the office (707-545-1554) or emailing her at vitamins@carlstonmd.com.